Transcript Care Coordination Plan

Care Coordination
A Key to sustainable
Healthcare
Irv Zeitler, D.O., VPMA
Sandra Morales, RN, MSN, CCM
Shannon Medical Center
Total Health Expenditure 2008
OECD health data 2012 http://www.oecd.org/els/healthpoliciesanddata/oecdhealthdata2012-frequentlyrequesteddata.htm
Total Health Expenditure 2008
Share of National Health Care
Expenditures
IOM (Institute of Medicine). 2010. The Healthcare Imperative:
Lowering Costs and Improving Outcomes: Workshop Series Summary. Washington,
DC: The National Academies Press.
 19.1%
of Medicare patients are readmitted
within a month of hospital discharge.
 56%
percent are readmitted within 6 months.
 Approximately
half of the patients with
chronic conditions like heart disease or
asthma actually either miss doses or don’t
take their medications as ordered. Nonadherence to medical regimens accounts for
a great deal of wasted spending and
potentially avoidable costly admissions.
A New Model of Care
•
A patient-centric strategy based on
what we refer to as the Shannon Care
Coordination program (SCC)
•
The SCC is a model that we believe
will be a cost-effective extension of
our community hospital that will
impact patient care beyond the walls
of the hospital.
Pre-med students are engaged in a
formal credit-based training program
that enables them to serve as health
coaches supervised by Shannon Care
Coordination team (SCC)
How it Works
Students
are formally trained by a faculty comprising
of physicians, a nurse coordinator, social worker,
psychologists, nutritionists, and other healthcare
professionals.
Upon
completion, these students begin a practicum
by shadowing members of the interdisciplinary team
and are thereafter progressively deployed to serve as
health coaches within the community.
The Health Coach’s Role
Under
team supervision, each health coach’s primary
responsibility is to inspire and motivate our patients to
become more actively engaged in their health and wellbeing.
Health
Coaches work with SCC health professionals
(Physician, nurses, social workers, dieticians, etc) to
reduce what ultimately falls though the cracks and
causes costly care that could be avoided.
Everyone Wins

Health Coaches do not get paid — but they receive college
credits for their participation in both the didactic sessions and
practicum. They also benefit from real world experience —
experience that could impact the success of our future
healthcare workforce.

Our patients benefit from a reliable dedicated patient-centered
continuum of care.

Our physicians receive the support they need for helping to
care for patients with a myriad of challenges.

Angelo State University could ultimately see an increase in
students in their healthcare programs who want to participate
in this program.

Our community realizes enhanced overall health and wellbeing.
Why Care Coordination?
People with multiple health and social needs are
high consumers of health care services, and thus
drivers of high health care costs.
The elevated cost of care in this population offers a
tremendous opportunity to craft a service delivery
plan that meets their needs more effectively at a
significantly lower cost.
We believe Care Coordination is a strategy that will
be effective, affordable and sustainable.
The Process
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Identify patients thru data review/screening
Obtain consent
Home visit
Collaborative development of a plan
Deploy health coaches- begin follow up
visits- Tele- health/medication boxes
Weekly review sessions
Monthly report cards
Quarterly updates
Identification

Data review
Database of high risk diagnosis
Diabetes, heart failure, coronary artery disease, Pulmonary disease(COPD)
Disease specific readmissions
Network within the facility
Focus on the 5%
Screening Tool
Socioeconomic
Cognitive/ Educational level
Medical/ Mental health
Adherence potential
Psychosocial stressors
Support
Patient Review
Gather additional medical
history to determine the
appropriateness of the program
for the patient
Obtain Informed Consent
 Overview
 Consent
of the program explained
and permission to discuss
completed
 Notification
 SCC
of enrollment sent to PCP
schedules initial home visit
Initial Home Visit
Completed by SCC Nurse
 Medication
 Discharge
reconciliation
instruction review
 Comprehensive
health profile (CHP)
 Review
rights and responsibilities
 Discuss
initial goals
Care Coordination Plan
Strategy development and
documentation- based on the
patients needs and goals
Implementation of the Plan
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Plan of action is discussed with the patient
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Goals are set in collaboration with the
patient
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Implementation begins based on agreed
upon plan and goals
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Utilize Med minder medication box
Deploy Health Coaches
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Health coach accompanies SCC team member
on visits
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The health coach continues to accompany a
team member until both parties are comfortable
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Health coach does not see patient alone until
cleared by SCC.
Health Coaches
Guidelines:

Health coach sees patient weekly in their
home
 A Health coach may accompany the patient to
physician appointment
 Progress note is documented at each visit
 A summary of the visit is emailed to SCC
team immediately after the visit
Health Coaches
DO NOT:
 Provide transportation
 Exchange any type of money or gifts
 Contact the physician for the patient
Health Coaches are under the direction of the
SCC team and contact a team member for any
issue that arises.
Weekly Review
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Progress report from health coach
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Progress report from SCC team members
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Individual patients discussed
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Strategies updated as needed
Report Card
 Scores progress on goals
Medical, Behavioral, nutritional, activity
Scale of 0-5:
 0=
 1=
 2=
 3=
 4=
 5=
goal is met
some improvement
stable; maintain strategies
stable; new plan needed
worsened
plan suggested patient declined work in this
area
Quarterly update
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CHP
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Medication reconciliation
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Outcomes tracking review
Example
Patient E.H.
Data review
Information from the high risk database:
• 3 of the high risk diagnosis
• (DM, CAD, COPD)
 6 ER visits for 2013 fiscal year
 6 additional ER visits that resulted in admission
Patient Review
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E.H. 42 year old disabled female
History includes:
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Obstructive sleep apnea- does not wear CPAP
consistently
Diabetes last A1C 11.8 (3/20/14)
COPD- 02 dependent
CAD
HTN
Hyperlipidemia
Smokes PPD
Height 5’1 Weight 249lbs = BMI 47
Obtain Consent
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E.H was approached while in the
hospital and offered the program
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Agreed to the program -consent was
signed
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Screening tool completed
Initial home visit
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Comprehensive health profile Reveals poor diet, poor health prevention, sedentary, relies on
others for assist with self care
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Medication Reconciliation
 5 large boxes of medications- 37 medications Forgets to take meds on occasion- no one helps her to
remember – stressor for the patient
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Review of Physician orders
 Pt to wear CPAP anytime she sleeps- has not been doing so
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Initial goals identified
 Lose weight, increase activity (wants to swim), “get out
of depression”
Care Coordination Plan
Primary focus:
Medical stability
 Stop smoking- reduce cigarettes by 1 per day
 Wear CPAP during the day if she sleeps- ask spouse to
remind her to put it on!
 Improve lung function- increase activity – 5 steps more a day!
 Medication reconciliation- determine correct medications
Secondary focus: Nutrition/ Activity
 Diet education- take the patient shopping/ budget for
healthy foods – reduce Dr. Pepper intake
 Start Gardening- increases activity, provides healthy
food, improves self esteem
Care Coordination Plan
Follow up visit
 Patient agreed to use Nicotine patch more
frequently- will keep count of # of days used versus
days smoking
 Agrees to plant 1 tomato plant in a pot in her yard
with plans to add more
 Reports she has not been napping during the day
since last visit and is wearing CPAP at night
 Expressed concerns about food supply due to
temporary loss of food stamps – obtained
perishable food items appropriate for diet
Going Forward
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Small Pilot program this summer
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Plan on additional 30 patients in the Fall with
17 returning students to be health coaches
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Additional staff and technology
There are three kinds of men:
The ones that learn by reading.
The few who learn by
observation.
The rest of them have to pee on
the electric fence
and find out for themselves.
-Will Rogers
QUESTIONS